Surgeon Volume and Elective Resection for Colon Cancer: An Analysis of Outcomes and Use of Laparoscopy

Abstract

BACKGROUND Surgeon volume may be an important predictor of quality and cost outcomes. We evaluated the association between surgeon volume and quality and cost of surgical care in patients with colon cancer. STUDY DESIGN We performed a retrospective study of patients who underwent resection for colon cancer, using data from the University HealthSystem Consortium from 2008 to 2011. Outcomes evaluated included use of laparoscopy, ICU admission, postoperative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes. RESULTS A total of 17,749 patients were included in this study. The average age of the cohort was 65 years and 51% of patients were female. After adjustment for potential confounders, compared with LVS, HVS and MVS were more likely to use laparoscopy (HVS, odds ratio [OR] 1.27, 95% CI 1.15, 1.39; MVS, OR 1.16 95% CI 1.65, 1.26). Postoperative complications were significantly lower in patients operated on by HVS than LVS (OR 0.77 95% CI 0.76, 0.91). The HVS patients were less likely to require reoperation than those in the LVS group (OR 0.70, 95% CI 0.53, 0.92) Total direct costs were $927 (95% CI −$1,567 to −$287) lower in the HVS group compared with the LVS group. CONCLUSIONS Higher quality, lower cost care was achieved by HVS in patients undergoing surgery for colon cancer. An assessment of differences in processes of care by surgeon volume may help further define the mechanism for this observed association.

Patient, Hospital, and Geographic Disparities in Laparoscopic Surgery Use Among Surveillance, Epidemiology, and End Results–Medicare Patients With Colon Cancer

“…22 We also found that as surgeon caseload decreased, so did the odds of receiving laparoscopic resection. Less than 5% of patients in our study had surgery performed by surgeons with annual caseloads of 30+ (based on the study population) whereas 43% had surgeons with annual caseloads of less than 10.…”

“…16 Previous studies have shown extensive variability in laparoscopic surgery utilization based on characteristics of patients [e.g., age, gender, race/ethnicity, socioeconomic status (SES), payer/insurance type, disease stage, comorbidity], hospitals (e.g., size/volume, teaching hospital status, urban/rural, geographic region) 3,5,8,17–21 and surgeon caseload. 22 To our knowledge, no studies have examined small area variability (e.g., at the county level) in the use of laparoscopic surgery in the US. Moreover, no studies concurrently examined variation across patients, hospitals, and geography.…”

Minimum Volume Discussion in the Treatment of Colon and Rectal Cancer: A Review of the Current Status and Relevance of Surgeon and Hospital Volume regarding Result Quality and the Impact on Health Economics

“…The statement deduced from our literature review, although extreme and by our count too low, should be discussed and be either confirmed or rejected by an expert committee with the aim to define profound minimum volumes. We also outlined the known threats of centralization, namely unjustified exclusion of high-quality surgeons, leaving excluded surgeons and hospitals [11,13,30], leaving emergency surgery to low-volume surgeons (LVS) or LVH (excluded from selective surgery), implicating worse experience with surgical oncological treatment of CRC offered to the patients with the highest risk [11], the realistic danger of overload concerning HV [11], and, last but not least, the observation that patients who traveled farther for their care had worse outcomes than expected. This statement, cited in the review by Etzioni et al [23] and called 'reverse distance bias' in their discussion, may be relevant for the US situation but not necessarily for Western European countries, e.g.…”

“…However, two of these papers also come to the conclusion that the impact of volume on outcome 'may be' positive when correlated to HVH [11,12] (these authors found a positive correlation for HVS). The estimation 'maybe' is made by one group only for the category HVS [13], but not for HVH. These authors reject a correlation between volume and quality for HVH.…”

Response to: ‘Back‐handed, left‐to‐right’ intracorporeal anastomosis technique during laparoscopic right hemicolectomy: a safe and reproducible approach by Zizzo M et al.

“…This may partially explain why, despite 25 years of evidence that a minimally invasive approach to right colon cancer achieves significant clinical and oncological benefits compared with open surgery, the application of laparoscopic colorectal surgery is still limited both in Europe and in the USA , and this is particularly true when performing an intracorporeal anastomosis. Most centres and surgeons in the UK and Europe still feel uncomfortable when attempting an ICA because of the fear of improper closure of the enterotomy and subsequent increased risk of a postoperative leak.…”